Variability in ACL Tunnel Placement Observational Clinical Study of Surgeon ACL Tunnel Variability

The Carver College or Medicine, University of Iowa, Iowa City, Iowa.
The American Journal of Sports Medicine (Impact Factor: 4.7). 04/2013; 41(6). DOI: 10.1177/0363546513483271
Source: PubMed

ABSTRACT BACKGROUND:Multicenter and multisurgeon cohort studies on anterior cruciate ligament (ACL) reconstruction are becoming more common. Minimal information exists on intersurgeon and intrasurgeon variability in ACL tunnel placement.Purpose/ HYPOTHESIS:The purpose of this study was to analyze intersurgeon and intrasurgeon variability in ACL tunnel placement in a series of The Multicenter Orthopaedic Outcomes Network (MOON) ACL reconstruction patients and in a clinical cohort of ACL reconstruction patients. The hypothesis was that there would be minimal variability between surgeons in ACL tunnel placement. STUDY DESIGN:Cross-sectional study; Level of evidence, 3. METHODS:Seventy-eight patients who underwent ACL reconstruction by 8 surgeons had postoperative imaging with computed tomography, and ACL tunnel location and angulation were analyzed using 3-dimensional surface processing and measurement. Intersurgeon and intrasurgeon variability in ACL tunnel placement was analyzed. RESULTS:For intersurgeon variability, the range in mean ACL femoral tunnel depth between surgeons was 22%. For femoral tunnel height, there was a 19% range. Tibial tunnel location from anterior to posterior on the plateau had a 16% range in mean results. There was only a small range of 4% for mean tibial tunnel location from the medial to lateral dimension. For intrasurgeon variability, femoral tunnel depth demonstrated the largest ranges, and tibial tunnel location from medial to lateral on the plateau demonstrated the least variability. Overall, surgeons were relatively consistent within their own cases. Using applied measurement criteria, 85% of femoral tunnels and 90% of tibial tunnels fell within applied literature-based guidelines. Ninety-one percent of the axes of the femoral tunnels fell within the boundaries of the femoral footprint. CONCLUSION:The data demonstrate that surgeons performing ACL reconstructions are relatively consistent between each other. There is, however, variability of average tunnel placement up to 22% of mean condylar depth, likely reflecting the difference in individual surgeons' preferred tunnel locations. Individual surgeons are relatively consistent in their cases of ACL tunnels.

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    ABSTRACT: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement. Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement. Cohort study (diagnosis); Level of evidence, 3. Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon's training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK). The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17). This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction. © 2014 The Author(s).